Provider Demographics
NPI:1275147266
Name:SHELLEY ANN SHAFFER
Entity Type:Organization
Organization Name:SHELLEY ANN SHAFFER
Other - Org Name:SHAFFER PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-380-0175
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-0463
Mailing Address - Country:US
Mailing Address - Phone:218-380-0175
Mailing Address - Fax:218-485-9105
Practice Address - Street 1:501 ARROWHEAD LN
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-7707
Practice Address - Country:US
Practice Address - Phone:218-380-0175
Practice Address - Fax:218-485-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-07
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1275147266Medicaid
MN1558841320Medicaid